Agenda item

To provide an update to the Health and Wellbeing Board (HWBB) on the Kirklees Health and Wellbeing Strategy (KHWS) priority of ‘Connected Care and Support.

 

Contact:  Rachel Millson, Senior Planning and Development Manager.

Rachel Millson, Senior Strategic Planning and Development Manager, advised the Board that the discussion would focus on some of the delivery of the Connected Care and Support priority within the Kirklees Health and Wellbeing Strategy.

 

The Board was informed that the Health and Care Plan, outlines how the Kirklees Health and Care Partnership will work together to drive change in response to national, regional and local directives. It does support the delivery of the Health and Wellbeing Strategy and some of the strategic documents that are developed for West Yorkshire, alongside the  West Yorkshire Delivery Plan which is the Joint Forward Plan. There are metrics, initial metrics that are within the document, which have been developed in the context  of the outcomes framework which supports the Health and Wellbeing Strategy.

 

The initial document was signed off by the ICB Committee in May 2023, and a commitment was made that it would be a live plan. It is recognised that things change and evolve, therefore the aim was to ensure that rather than starting with a new draft of the strategy every year, there would be a commitment to update and evolve the plan. Just to reinforce that the delivery is overseen by the Delivery Collaborative and all the partners who work within health and care have a seat on that delivery collaborative.

 

Referring to the presentation slides, the Board was advised of the system wide, strategic priorities that are within the plan, cuts across the life course approach, as outlined in the Health and Wellbeing Strategy, Starting Well, Living Well, and Aging Well programmes. Dying Well is a programme in its own right, however, it is considered in each of the other programmes and mental wellbeing, which can affect an individual at any point of the life course.

 

There are partnership strategic priorities and then there are organisational level priorities that are national directives to focus on in the short term, listed as priority actions including:

 

-      Improving access to health and care

-      Holistic approach to out of hospital care

-      Crisis response

-      Workforce

 

Patrick Boosey, Transformation Programme Manager ICB, provided an update on the Starting Well Programme. The Board was advised that the Starting Well Board, has an alignment with the Children and Young People’s priorities and the subsequent resource to deliver these. It is a single place for existing Boards and groups to report to, enhancing partnership working, facilitating development of relationships, connected decision making and reducing duplication across the partnership. It is a forum to discuss complicated system wide strategic issues and  opportunities to share learning and risk.

 

It is a single assurance mechanism to support decision taking processes, development of a system wide work plan, supporting groups such as the Ambition Board. It is a contact for West Yorkshire level work, for example, the Integrated Care System, alignment of data and intelligence, where there is qualitative information e.g. Children and Young People’s Voice, and quantitative information and numerical shared data sets. It is a partnership approach to delivering the Families Together work in absence of additional central funding from government and it is enabling better connection of services by ensuring links at an organisational level and also with communities.

 

The priorities to be delivered over the next 12 months, includes the delivery of the Health and Care Plan, the Families Together implementation model across Kirklees, improvement in metrics associated with the first 1,001 days of a child’s life, and creating a Starting Well Strategy and work plan to bring together a range of different partner priorities agendas and programmes of work. The aim is to integrate the Children and Young Persons Voice, to strengthen representation and inclusion within the work plan, specifically looking at commissioning and strategy and also developing a system wide standardisation metrics focusing on outcomes and the difference made across the system.

 

The next steps are to continue with further development of the Starting Well Board, with a focus on strategic partnership outcomes, development of the Families Together model with a focus on four key sites across Kirklees that will be offering a comprehensive rotating offer of services with face-to-face availability. An online digital platform offer, universal branding and marketing materials produced and utilised by partners. The evolution of the four partnership boards which feed into the Starting Well Board, these include the Youth Development Partnership, the Emotional Health and Wellbeing Partnership, Early Support Partnership Steering Group and the Early Years Development Board.

 

An action plan is to be produced to support the aims and ambitions highlighted in the Kirklees Health and Care Plan. Creation of a Starting Well Strategy which brings together the four board’s ambitions and integrate the early help supporting families and Family’s together agenda. Support the completion of the Starting Well section within the KJSA with associated colleagues and a presentation to the ICB Committee in August to update on progress.

 

The Board was asked to:

1.    Support to develop and/or facilitate a shared platform for the Starting Well partnership to work on i.e.: Teams/SharePoint

2.   Resources will be required to progress a range of workstreams and projects, how do we fund this as a partnership with mounting pressures across the system i.e.:

-  Investment in Families Together (buildings, branding, service provision)

-  Development of an online platform to improve access and communication

-  Staff time to properly resource projects

-  Sharing of expertise, skills and assets i.e.: policy writing,  marketing/communications, clinical leadership

Jo Hilton-Jones, Public Health Manager, presented information on the Living Well Programme, on behalf of Alison Steed, Senior Transformation Manager, ICB manager lead for the Living Well Programme.

 

The Board was informed that in terms of the Living Well Programme, the context is the fact that there is an aging population, more people are living with long term conditions, there are increased financial pressures and therefore there is a heightened need to focus on the prevention and inequalities aspects. Making the shift to having a community based prevention approach, whilst also focusing on early diagnosis and the secondary prevention approach in terms of the management of long term conditions, is a local priority.

 

The driver is enabling the partnership approach, to focus on better integrating the long-term condition work and delivering key outcomes. In terms of aims and objectives, the focus is on prevention, early identification, and secondary prevention. The delivery of the strategic priorities and responsibilities in terms of the long-term plan and other strategic commitments, the focus of those long term conditions is on cardiovascular disease, including stroke, diabetes and respiratory conditions that affect many of the population across Kirklees. Identifying commonalities to reduce the risk factors and preventing onset and building on those programmes such as the Core 20 Plus 5 initiative to better engage and deliver the prevention approach.

 

In respect of progress, Living Well is not as far ahead as some of the other programmes, and is not currently operating in a formal structure. The programme and workstreams are still being shaped and the work is still progressing,  however, at this point there is no Senior Responsible Officer, which has been a barrier to be able to formally establish the programme.

 

There has been an initial workshop with key strategic partners exploring priorities looking at the collective focus, and what will be the initial scope of the programme. There are four draft workstreams focusing on data, and how it can be better used to inform the work. The sharing of data is still an ongoing challenge.

 

Although currently the programme does not have a  formal programme board, this work is still being driven forward, and there are already some real successes. Part of the delivery in terms of the secondary prevention agenda, is the National Diabetes Prevention Programme, which is a national programme for people that have been identified as being at a high risk of developing diabetes, which can be described as pre-diabetes. People can be referred via their GP; therefore, it is important that there is early identification. Kirklees is continually achieving the referral trajectory, which is positive, it is trying to enable people to access those programmes, that can hopefully reverse the diabetes.

 

One of the pieces of work that is being progressed is NHS health checks, commissioned by Public Health, which is moving towards a targeted approach, and developing a new specification for that. There is also a Community Champions Campaign that is currently running on cardiovascular disease, and there has been some positive feedback with approximately 800 one-to-one conversations with Community Champions. From the feedback received, it highlighted that many people did not know what cardiovascular disease was and why taking their blood pressure medication was important and what the risks of not taking it were. There has been excellent support from the West Yorkshire ICB, they have provided 15 blood pressure monitors for the area and Community Champions have been trained in using them, are going out, and taking people’s blood pressure.

 

One of the key challenges to highlight is the financial challenge, key to the delivery of this programme across the spectrum are the Community Champions, they are valuable as part of the work and support the access to the prevention messages. In addition, the Community Anchors, because without the Community Anchors and their capacity, and infrastructure, it will be a struggle to have Community Champions and at the moment their funding runs out at the end of this financial year.

 

Nicola Cochrane, Transformation Programme Manager ICB and the programme manager leading on the Aging Well Programme, informed the Board that this programme has been established for a while, with Karen Jackson as the Senior Responsible Officer, supported by a number of workstream leads.

 

The main aim with the programme, is to take an integrated proactive approach across the wider system and community, to enable the ageing population to help shape the environment and to optimise their own independence and wellbeing. Where necessary, be supported to live as safely and independently for as long as possible. When they do end up at crisis point there are services able to respond.

 

The programme has been developed based on national and regional guidance and recommendations such as the Long-Term Plan, Yorkshire and Humber State of Ageing Report, and the World Health Organisation 8 Domains of Healthy Ageing. The programme priorities are reviewed regularly, and when new guidance is published, the programme evolves to ensure it is aiming to achieve best practice where possible.

 

To meet the recommendations within the publications, seven workstreams have been established, these include:

 

-          Proactive Care which focuses on providing personalised, co-ordinated, multi-professional support and interventions for people living at home with Frailty to maintain independent living and reduce the use of unplanned care

-          Kirklees becoming an Age-friendly community through exploring what communities value, working with the WHO 8 domains

-          Falls is a newly established programme within Ageing Well. There is a system wide workshop in September to start to develop the work plan around this

-          We have an ambition to develop a robust and resilient Care Sector, taking a partnership approach through the development of some workstreams  with key areas of focus

-          Discharge workstream and this focuses on embedding and mature the home first discharge approach to improve patient outcomes and improve patient flow out of hospital

-          Virtual Ward which enables patients who would otherwise be in hospital to receive acute care and treatment in their own home

-          and Urgent Community Response which provide urgent care within 2 hours of need to people their own homes to help avoid hospital admission

 

There are also strong links with key interdependent and enabling programmes such as the other well programmes, Mental Health, Housing, Carers and Civic Participation and Employment.

 

There is a well-established and represented programme board with membership from partners across the system to provide a governance route. A set of high-level metrics have been developed to monitor progress and are discussed monthly at the board. Overall, good progress is being made against these with the majority of them improving month on month.

 

Safdar Adnan, Kirkwood Hospice, provided an update on the Dying Well Programme advising that it is positive that it has its own ‘well.’  Four initial pieces of work have been identified by the Dying Well Board to progress, while the wider programme is being developed. These are, stigma and conversations about death and dying, identification and care planning, bereavement and care at home. The Community Champions will be undertaking a campaign around death and dying and the stigma surrounding that, and the barriers to accessing care and support.

 

There will be some rich learning that will come out of the work as highlighted in the DPH annual report, and it is important to ensure that people’s experiences, help form and shape the Dying Well Programme ensuring that all parts of the system are involved on the Dying Well Board and the workstreams. Historically, there has been some gaps, for example, Primary Care and that will be an area of focus and will need to be supported by clinical and programme resource.

 

Some of the other work that is currently being undertaken, is the development of an integrated model of care, following work undertaken by Healthwatch. One of the key themes that came from that work was in regard to the support being offered to people that were being cared for at home.

 

In respect of the programmes, the Board was asked to consider the following questions:

 

Starting Well Programme

-      Support to develop and/or facilitate a shared platform for the Starting Well partnership to work on i.e.: Teams/SharePoint

-      Resources will be required to progress a range of workstreams and projects, how do we fund this as a partnership with mounting pressures across the system

 

Living Well Programme

-      Support in identifying a Senior Responsible Officer

-      Support a partnership approach for sustaining funding for community champions campaigns and Voluntary sector organisations to support prevention related activities

 

Ageing Well Programme

-      Nothing to escalate

 

Dying Well Programme

-      Lack of clinical leadership to support the Programme in the long term and the impact of this on progress

-      How to improve primary care involvement within the Dying Well Board and workstreams

 

RESOLVED:

 

That

 

i)         the officers be thanked for providing an update on the Connected Care and Support Priority of the Kirklees Health and Wellbeing Strategy.

 

ii)       the questions to the Board be considered.